Sunday, October 14, 2018

Why I Might Seem at Times to Prefer Bigger and/or More Powerful Government


The obviously needful advance disclaimer: I DO NOT.

In fact, given my druthers I would do away with the state entirely and would press Murray Rothbard's Magic Button right now if it appeared in front of me.

Within the existing state system and in terms of practical politics, I will support any policy move that I regard as genuinely "in the right direction" -- that is, any measure that I believe reduces the size, scope and power of government in any area and on any issue -- without deluding myself into believing that that measure gets to the root of the problem.

And then we have cases where none of the options "on offer" in a practical sense seem to meet the "right direction" criterion. At which point I look at those options, try to pick the one that seems least awful on non-libertarian criteria, and perhaps give that option lukewarm rhetorical support versus the other options (while still calling for the abolition of the state and/or real "right direction" moves).

For example:

In comments on an earlier post on healthcare, Jim L writes "I am usually a free marketer, but we don't have that.

To which I reply (as I have similarly said elsewhere and in other formats): "What we have is a mix of left-wing socialized healthcare (about 20% on Medicare, about 20% on Medicaid, 3% enrolled in VA healthcare, etc.) and right-wing socialized healthcare (HMO/PPO/ObamaCare, etc.). I'd rather have a free market. But if we're going to have almost entirely socialized healthcare, I suspect that 'single payer' would be better. Less complex, possibly less expensive."

No, I don't endorse "single payer," or "Medicare For All," or any of that nonsense. But if someone handed me a magic button and the only function it served was to let me choose between the existing system and "single payer," I'd probably go with "single payer."

To explain why, let me butcher and repurpose a quote from Abraham Lincoln:

"As a nation, we began by declaring that 'healthcare is something the market provides.' Over time we came to practically read it 'healthcare is something the market provides except for the elderly, and the poor, and veterans, and whenever the AMA monopoly doesn't like the market.' Increasingly more so over the last 45 years, we now read it 'healthcare is something the market provides except for the elderly, and the poor, and veterans, whenever the AMA monopoly doesn't like the market, and when Big Pharma and Big Insurance can lobby to have us all forced into its HMO/PPO schemes via e.g. tax policy.' I should prefer we make no pretense of loving the market and take our socialism pure, and without the base alloy of hypocrisy."



Does Anyone Really Know How Much Medical Care Actually Costs?


Presumably so -- I've heard of practices and clinics that refuse insurance of any kind and are entirely "cash and carry." Even those prices are distorted by the overall climate, but at least they're prices directly negotiated between provider and patient, so they presumably communicate some kind of coherent information on cost of provision, scarcity of staff and equipment, etc.

For those of us with "insurance," not so much.

Case in point:

I recently had an office visit with a specialist.

The medical equipment involved included, to the best of my recollection, a scale, a thermometer, and a sphygmomanometer. In other words, stuff that is neither especially expensive nor costs a lot to operate (like, say, an MRI machine).

The visit's total length was around an hour, probably 20 minutes of which was spent waiting due to technical difficulties (a regular old desktop computer went down -- hard drive problem that kept it from booting up) and patient backlog (some older patients ahead of me had problem with the computerized check-in kiosk, etc., and it kind of cascaded). But let's generously call it an hour of raw time and three person-hours of work time between the doctor, the physician assistant (who did most of the heavy lifting), and other staff (receptionist, nurse, et al.). My real guess is less than two person-hours because most of those people are multi-tasking, but I don't want to lowball the costs of provision.

My co-pay was $35. Not bad at all.

According to billing, the full charge for the visit was $747.

That seemed high to me until I did some research on salaries, etc. In addition to going high on person-hours involved, I went with the higher numbers I found for doctor pay, etc. and used the two highest salaries I found (doctor and physician assistant), and multiplied even that by 1.5 to account for non-salary costs to employ someone. I came up with staff costs of about $420.

According to Becker's Hospital Review, median hospital labor costs as a percentage of operating revenue run 54.2%. Which, based on my labor calculations above, would mean that the hospital expected to bring in about $775. So the "real" price of my appointment (as opposed to my co-pay) was only about $28 (3.5%) off of what the labor numbers I SWAGed would lead me to expect.

The combined "real" bill for my echo cardiogram and nuclear stress test last week came to $4,787. Of course, those things involved expensive equipment, drugs, more focused staff time and more of that staff time involving people with specific technical credentials, etc. But once again my co-pay was $35.

If the whole pricing scheme just sounds bizarre and even crazy to you, it does to me too. But it occurs to me that my "insurance" pricing is tasked with absorbing some of the difference between actual costs and what the hospitals and clinics can bill for the same services when provided to Medicare and Medicaid patients, administrative costs of complying with government regulations, etc.

That is, I expect that in a free market, cash on the barrelhead pricing would be significantly less than the numbers you see above. But also more than I could afford to pay ;-)



Saturday, October 13, 2018

Florida Ballot Issues Endorsements: No on Amendment 3


I'm not sure how many of the issues on Florida's November ballot I'll bother analyzing here, but at least one or two, starting with Amendment 3. The relevant parts, excluding the word definitions section, etc. ...

This amendment ensures that Florida voters shall have the exclusive right to decide whether to authorize casino gambling in the State of Florida. This amendment requires a vote by citizens’ initiative pursuant to Article XI, section 3, in order for casino gambling to be authorized under Florida law. This section amends this Article; and also affects Article XI, by making citizens’ initiatives the exclusive method of authorizing casino gambling.

...

Nothing herein shall be deemed to limit the right of the Legislature to exercise its authority through general law to restrict, regulate, or tax any gaming or gambling activities. In addition, nothing herein shall be construed to limit the ability of the state or Native American tribes to negotiate gaming compacts pursuant to the Federal Indian Gaming Regulatory Act for the conduct of casino gambling on tribal lands, or to affect any existing gambling on tribal lands pursuant to compacts executed by the state and Native American tribes pursuant to IGRA.

In short, under Amendment 3 only the voters (not the legislature) can allow non-Indian casinos, but the legislature can still do things that make casinos more difficult and expensive to open or operate.

Who, I wonder, could be behind such an idea? Well, the top three donors to "Voters in Charge," the group pushing the amendment, are:

  • Disney Worldwide Services, because Disney doesn't want to compete with casino gambling for tourist dollars in Florida
  • The Seminole Tribe of Florida, because the tribe doesn't want to compete with non-Indian-owned casinos in Florida
  • No Casinos Inc., an anti-gambling (at least in Florida) organization

The "purpose" of Amendment 3 may be to put "voters in charge" of whether or not to allow casino gambling, but the goal of Amendment 3 is to make sure casino gambling isn't allowed.

My preferred casino gambling amendment to Florida's constitution would look something like this:

Don't want to own, operate, or patronize a casino? Don't own, operate, or patronize a casino. Don't want others to own, operate, or patronize casinos? Well, feel free to try to talk them out of doing so if that floats your boat, but it's not your decision to make for them. Things would probably just be much better all around if you minded your own f**king business.

That option not being on the menu, I intend to vote no on Amendment 3 and encourage others to do likewise. Not because I trust the legislature to mind its own f**king business, but because legislators at least might have some incentives (increased tax revenues, perhaps some expensive meals paid for by lobbyists, etc.) to possibly at least allow these businesses to operate.

Yes, there are competing incentives (I'm sure Disney, the Seminoles, and the evangelical obsessives or whoever is behind No Casinos Inc., can lay out a great prime rib and crab leg buffet too, as well as contribute to pols who toe their line and to opponents of pols who don't), but the prohibitionists wouldn't be behind this if they didn't think it was going to be, at least in the long run, a more effective and less expensive way of protecting their business interests through government force and/or running everyone else's lives through same.

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